Patient Registration Form

PATIENT INFORMATION

SS/HIC/Patient ID #:

Date:

Last Name:

First Name:

Middle Initial:

Address:

City:

State:

Zip:

E-Mail:

Sex:

M F

Age:

Birthdate:

Marital Status:

Married Separated Widowed Divorced Single Minor Partnered for years

How many years partnered?

Patient Employer/School

Occupation:

Employer/School Address:

Employer/School Phone:

Spouse's Name:

Birthdate:

Spouse Employer:

SS #:

Whom may we thank for referring you?

DENTAL INSURANCE

Who is responsible for this account?

Relationship to Patient:

Group #:

Insurance Co.:

Is patient covered by additional insurance?

Yes No

Subscriber's Name:

Birthdate:

SS#:

Relationship to Patient:

Insurance Co.:

Group #:

Assignment and Release

I certify that I, [Enter the name of insurance company below] and/or my dependent(s), have insurance coverage with

and assign directly to:

all insurance benfits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use m health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient,Guardian or Personal Representative:

Name of Patient, Parent, Guardian or Personal Representative:

Date

Relationship to Patient:

PHONE NUMBERS

Phone:

Work:

Ext:

Cell:

Spouse's Work

Best time and place to reach you:

IN CASE OF EMERGENCY, CONTACT, (Specify someone who does not live in your household.)

Name:

Relationship:

Home Phone:

Work Phone:

DENTAL HISTORY

Reason for today's visit:

Former Dentist:

City/State:

Date of last dental visit:

Date of last dental X-rays:

How oftern do you floss?

How often do you brush?

HEALTH HISTORY

Have you ever used a bisphosphonate medication? (Common brand names are Fosamax, Actonel Atelvia, Didronelm Boniva)

Yes No

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combination of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) & Redux (dexflenfluramine).

Yes No

Type of Hepatitis:

Do you wear contact lenses:

Yes No

Women:

Are you pregnant?

Yes No

Due Date:

Taking birth control pills?

Yes No

Are you nursing

Yes No

MEDICATIONS

List any medications you are currently taking and the correlating diagnosis:

Add another medication

Pharmacy Name:

Phone:

ALLERGIES

Mark if it applies:

Aspirin

Barbiturates (Sleeping pills)

Codeine

Iodine

Latex

Local Anesthetic

Penicillin

Sulfa

Others (Please specify):

UPDATES (to be filled in at future appointments)

Add another form

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Patient Registration Form

PATIENT INFORMATION

DENTAL INSURANCE

Assignment and Release

PHONE NUMBERS

DENTAL HISTORY

HEALTH HISTORY

Women:

MEDICATIONS

ALLERGIES

UPDATES (to be filled in at future appointments)

Smile Works Family Dentistry